The Caesarian Path

The Caesarian section has a fascinating, if largely apocryphal history. In all likelihood it was probably a procedure of last resort to save the unborn child when its mother was already dead or near death. That the famous Julius Caesar –like Shakespeare’s MacDuff- was ‘from his mother’s womb untimely ripped’ seems unlikely, however appealing the etymology. In fact, the name may well derive from the Latin verb ‘caedere’ –to cut- and hence the cognomen (originally a nickname). Pliny the Elder, according to Wikipedia, ‘refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, “cut from the womb” giving this as an explanation for the cognomen “Caesar” which was then carried by his descendants.’

At any rate, before the days of appropriate antisepsis let alone adequate analgesia, the survival rate for both the mother and baby would have been dismally low. And despite isolated reports of its use throughout recorded history in such diverse countries as India, China, and even Babylon, it was always a procedure of desperation. A triumph, as Samuel Johnson once wrote in another context, ‘of hope over experience.’

Unfortunately it has now become merely a triumph of experience -a default position assumed at what seems to be the slightest provocation. The fact that it is an operation that can be booked in advance under some circumstances, and therefore superimpose a degree of predictability on the scaffolding of the anticipated chaos of labor, has been seen as desirable in some quarters. And in fairness, there are those for whom labor carries undue risks for either mother or baby and its avoidance would be prudent if not lifesaving. The issue, I think, is in the interpretation of risk.

The other, perhaps more problematic concern, is that of choice. At least in a system of limited resources, or one in which the public purse is providing medical coverage, one could ask whether an elective Caesarian section for no other compelling obstetrical reason than patient choice, is a sustainable option. Or even a desirable one.

So, what about in a user-pay system? Is it merely a matter of supply and demand: build more hospitals to accommodate the needs and whims of those who can afford them? Is that an efficient use of their resources? Is it even an ethically defensible position? The matter has finally prompted the Brazilian government to wade in, as an article in the July 7/15 BBC news reports: http://www.bbc.com/news/world-latin-america-33421376

Of course, there are many reasons for elective Caesarian sections –some of which are the result of previous and unsuccessful attempts at vaginal delivery that necessitated Caesarian deliveries at that time. The desire to avoid a similar and frustrating trial of vaginal delivery is certainly understandable –if not always necessary- under those circumstances. These are the so-called elective repeat Caesarians. Others, as I indicated, are obstetrically mandated because of developing or pre-existing risk factors –once again, hard to argue against. There is an interesting and informative article that attempts to put the Canadian experience (2007-2011) into perspective –a classification system (the Robson Classification System) that can be used to make international comparisons in Caesarian section rates: http://www.jogc.com/abstracts/full/201303_Obstetrics_1.pdf

But getting back to the situation in Brazil. As the BBC article suggests, ‘Eighty-five per cent of all births in Brazilian private hospitals are caesareans and in public hospitals the figure is 45%’. And the new government rules ‘…oblige doctors to inform women about the risks and ask them to sign a consent form before performing a caesarean. Doctors will also have to justify why a caesarean was necessary. They will have to fill in a complete record of how the labour and birth developed and explain their actions.’ That they may not have been doing this routinely before is troubling, to say the least.

Also, ‘Each pregnant woman will now be assigned medical notes which record the history of her pregnancy, which she can take with her if she changes doctors.’ I would have thought this practice would have been universal and intuitive -without the need for a government fiat.

But, as worrisome as all of this seems, there is another, perhaps more subtle pressure on the woman to opt for a Caesarian delivery in Brazil: ‘Women who want to give birth naturally in a private hospital have reported finding all the beds are reserved for scheduled deliveries. There have been numerous reports of women going into labour without a caesarean scheduled and being forced to travel from hospital to hospital in search of a bed.’ And as Pedro Octavio de Britto Pereira, an obstetrician and professor at the Federal University of Rio de Janeiro, said in an interview with BBC Brazil last year, “The best way to guarantee yourself a bed in a good hospital is to book a caesarean.”

Of course the blame does not wholly fall on the medical profession there –nor even, perhaps, on their preferred management strategies in pregnancy. ‘Researchers say many women also see caesareans as more civilized and modern, and natural birth as primitive, ugly and inconvenient. In Brazil’s body-conscious culture, where there is little information given about childbirth, there is also huge concern that natural birth can make women sexually unattractive.’

It is always dangerous to judge another country and another culture by our own standards. Our own sensibilities. And yet the risks are transnational and universal. They do not disappear simply because of a differing national mythos. Surgery is surgery; complications are inevitable co-travellers with it in spite of all precautions, and good intentions -the hidden, unwanted occupants of every operating theatre. And while we may never be able to stem the tide of primary elective Caesarians –even education on the subject has challenges overcoming fear or fashion- we may be able to convince women that their choice does not come without baggage. Unintended risks. To journey through a new geography, it helps to have thought about it first; planned the route to avoid unnecessary problems; consulted a knowledgeable guide –someone who will travel along with you. And remember what Seneca wrote: ‘Be wary of the man who urges an action in which he himself incurs no risk’.

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Forget it?

Memories are tricky things. Sometimes they’re not around when you want them, only to arrive later, when you don’t; sometimes they surround you, pester you, like wasps at a picnic. And other times you can’t find them at all no matter where you look. But the really tricky ones are those that never happened and yet they stand up and wave at you from the crowd as if they’ve known you for years. Sometimes they convince you…

The idea of false memories –or let’s be kind… mistaken memories- is not a new one, but several well-publicized instances recently have brought it to public attention. In the age of social media, of course, the cases are instant hits. Take the hyper-publicized example of Brian Williams, the popular NBC news anchor who claimed he remembered being shot down in a helicopter in Iraq 12 years ago. When this was disputed by veterans at the scene, he was forced to step down from his job. http://www.bbc.com/news/world-us-canada-31220600

Because most of feel we can rely on our own memories, the feeling was that he had obviously lied –perhaps to enhance his own role and bravery in the combat, or because of the notorious ‘fog of war’ –that state of confusion that arises in states of extreme stress and chaos on a battlefield.

So which was it? Fog, or lie? Or maybe post traumatic stress disorder (PTSD)? Well, the matter is more complicated than it might seem on the surface. There has been a lot of work done on ‘false memories’ of late –how and why they form. For example: https://blogs.brown.edu/recoveredmemory/files/2015/05/Loftus_Pickrell_PA_95.pdf  Memories, as one of the psychologists explained, are not like videos recorded on a DVD –the same pictures, the same information each time you play them. They are more like the material on Wikipedia –able to be modified or even changed completely depending on the need or as a result of any new information that might come along. They are, in a word, mutable. Unreliable.

And yet, unconfronted, the memories seem infallible and in most of our experience it seems counterintuitive that they would be otherwise. After all, why have memories if we can’t rely on them? I suppose the simplest explanation is that if we remembered everything that happened throughout the average day –let alone a lifetime- there would be insufficient storage to say the least. Our brains must pick and choose relevance, perhaps adding or subtracting things for efficiency or continuity as information and situations change… It used to be termed ‘retrospective falsification of memory’. Or, as the authors of the above mentioned paper describe it: ‘Relatively modern research on interference theory has focussed primarily on retroactive interference effects. After receipt of new information that is misleading in some ways, people make errors when they report what they saw. The new post-event information often becomes incorporated into the recollection, supplementing or altering it, sometimes in dramatic ways. New information invades us, like a Trojan horse, precisely because we do not detect its influence.’

This type of situation is certainly not unknown in the medicolegal kingdom. In the course of frightening and unexpected events, there is sometimes a variation of perception –especially if the event is associated with injury or seems to be the result of negligence or incompetance. Totally understandable, obviously, and yet there are often variations of what actually occurred that are remembered.

But the issues are not always of putative malfeasance. Sometimes they have a more personal tone.

I hadn’t seen Joanna for several years, the computer said. I have to admit that nothing about her was familiar. I had no record of seeing her for the pregnancy, but apparently I’d delivered her baby so I must have been on call for consultations that day for my colleagues. She’d not come back for a post partum check, so I assumed she had simply gone back to her regular doctor or midwife. And now, six or seven years later, she was sitting in the waiting room staring at the wall. She didn’t look at all happy to be there. The referral letter said she just wished to talk about a problem. Referral letters are not always helpful…

I smiled at her as I crossed the carpet to where she was sitting and extended my hand. The one that reached out to me was sweating, limp, and tentative –as if, given a choice and not witnessed by the others in the room, it would have stayed rooted in her pocket. Joanna was a small woman with short, tightly curled black hair, held in place by a yellow ribbon so tightly wound around her forehead that the skin in the immediate vicinity seemed blotched and ill. I wondered for a moment if that was why she didn’t return my smile –she couldn’t. It only let her frown.

In the office, she sat in the uncomfortable captain’s chair across from me like a post with knots for eyes. They didn’t move, but instead seemed fixated on something half way across the desk. I tried to put her at ease by asking her how she was but was met with a wooden silence; not so much as a splinter moved. I let the silence lie fallow for what seemed an eternity and then, feeling her anger, asked her as gently as I could, why she’d come back to see me after all these years.

The knots on her face moved upwards a few degrees, and the post shivered. “This is not easy for me, doctor. I didn’t want to come, but my family doctor said I should talk about it with you…”

I leaned my forearms on the desk to show I was listening, and asked her what she wanted to talk about.

She sighed and shifted uneasily in her chair. Suddenly the knots became eyes and they stared at me like the barrels of two guns. Her face tightened and her jaw clenched for a moment. “The delivery!”

I waited, but she remained silent. I wasn’t sure what she wanted me to say. I couldn’t remember it at all, although my secretary had been able to get the delivery note I’d dictated. I skimmed through it quickly, but apart from a ten pound baby and a vaginal tear as she apparently pushed it out before I could control it, I could find nothing else. “Was there something about the delivery you wanted to ask me?” I said when it was clear she was waiting for me to comment on it.

Her eyes grew larger and angrier. “The forceps! I told you I didn’t want forceps! My first baby was large and I didn’t need them for her…” She was almost shouting and little strands of saliva escaped with every word. “I told you..! And then because of the forceps, I got that tear in my vagina that took weeks to heal. We couldn’t have sex for almost 2 months!” Suddenly, tears appeared and ran down her cheeks. “I told you I didn’t want you to use forceps! I told you… But you wouldn’t listen. You kept telling me the baby’s heart was too low and she had to be delivered right away.”

I could see her clenching and unclenching her fists as she talked. “My secretary has managed to find the report I dictated on the delivery. I’m sorry I don’t remember more, but let me read it again…”

“I’ll bet you don’t remember it!” she said between clenched teeth. “The nurses told me about you before my midwife consulted you. Apparently you like forceps and are pretty good at it…” She shook her head sadly and looked at her lap for a moment. “But I told you I didn’t want forceps and yet you went ahead and used them on me!”

I pulled up the delivery report and read it carefully. I’d been exceptionally detailed in my dictation that night, so perhaps I had been concerned that the baby’s condition might have warranted it. I’d been called by her midwife in the middle of the night because she had been pushing for three and a half hours without much progress. The head was not coming down the vaginal canal and the baby’s heart rate was beginning to show signs of distress. I had examined her, explained the situation, and then told her the options: continue to push, although I didn’t recommend this because she hadn’t made any progress after all that time, and the baby’s heart rate was beginning to show decelerations indicative of distress; caesarian section; or trial of forceps (a concept meaning if the forceps weren’t successful after a reasonable try, that caesarian section would be the fall-back option.) She hadn’t wanted a Caesarian, so I’d asked the nurse to get the forceps ready –just in case. Then, when the nurse had entered the room with the forceps, Joanna had become angry and said she would not accept forceps for delivery.

There followed a sudden, profound, and prolonged fetal heart rate deceleration and something had to be done to help the baby right away. The situation demanded an immediate judgment call, and that meant the forceps. But just as I was reaching for them, she gave a mighty push and delivered the baby. Unfortunately I’d been unable to control the head on such unexpectedly short notice, so she’d sustained a vaginal tear. It hadn’t been terribly large, and I’d been able repair it without much difficulty. Baby seemed fine, and there were smiles all around.

As I was finishing reading the report, I could hear her voice repeating again and again “Why did you use the forceps, doctor. I told you not to use them…”

I forced a smile. “I didn’t, Joanna. The baby was in trouble and I needed to get her out quickly, but I didn’t get a chance to use them. You pushed her out as I was turning to get them ready.”

“But I heard them! I heard them clanking…”

Forceps are metal and as the two sides are assembled they often make a metallic clanking noise. (They superficially resemble salad tongs, although unlike tongs, they don’t actually squeeze the head in anything like the same way. They fit more like a helmet over the head and guide it down the vaginal canal like a dilating wedge in front.) I shrugged politely. “It was an emergency for the baby. She needed to be delivered right away, so I was probably getting them ready when you had that really strong push.” I chuckled at something and she stared at me. “Sometimes I think that just the threat of using them is as good as using them. Nothing motivates stronger pushing than clanking the forceps!”

First I saw her teeth and then a smile worked its way slowly into the space around them. “But I distinctly remember you putting them on… I think…” Her eyes wandered to the window behind me for a moment. “Can I see your report?”

I smiled as much in relief as at the dissolution of the tension in the room. “Of course.” I punched a couple of keys and the report chugged its way out of the printer. I handed it to her and sat back while she read it. Actually, she must have read it several times, each time shaking her head in steadily diminishing disbelief. Finally she folded it up and put it in her purse. “All this time…” Her eyes sought mine and I could see they had softened from birds of prey, to… the prey itself. “But I remembered it so differently…”

“Would you like me to see if I can get a hold of the nurses reports as well?”

A large, genuine grin spread across her head dividing her eyes from her chin as she shook her head a final time. “I’m so sorry, doctor… All this time…” Suddenly a thought occurred to her. “Tell me one thing, though.” She tore her eyes away mischievously and they flitted briefly about the room. “Were you wearing an earring that night?”

I must admit I blushed at the question and nodded my head. “It was a phase,” I added quietly.

She giggled and reached for my hand. “Well at least my memory didn’t screw everything up…”

The Size of the Dog

In the hazy light of retrospect I can still see her lying there on the hospital bed scowling at me. She was clutching her baby as if she’d won it in a game in which she’d cheated. In fact, I suppose she had… But I’m getting ahead of myself. Way ahead.

I’d first met Mary a few years before when I was on call at the hospital. She was pregnant for the first time and was not progressing in her labour. A short woman -she was less than 5 feet- with a tall and heavy husband, she looked almost out of place beside him in the room. They both looked at each other as I walked in; clearly a consultation with an obstetrician was not what they had anticipated. They’d been followed throughout the pregnancy by a midwife, and had only come to the hospital under duress. They both desperately wanted a normal delivery and despite the reassurances of their caregiver that she was just being safe, they suspected the worst.

Mary confronted me with her eyes before I could even approach her bed. “I don’t want an epidural,” she said and metaphorically crossed her arms to ward me off.

“Good, ” I said, “because I’m not the anaethesiologist.”

“That’s not what I meant, and you know it…” her face was hard and then suddenly her forehead wrinkled so much I’m surprised she could even see me. “And I don’t want a Caesarian Section either!” Then she seemed to pout. “Babies do better after vaginal birth..!” She thought about it for a moment. “And so do mothers!”

I could hear the exclamation marks from across the room so I put on my best smile and walked towards the bed.  I glanced at the midwife.  “Susan tells me you’ve been contracting now for almost twelve hours at home….”

“Yes, but they weren’t very strong.”  She noticed Susan staring at her. “Well,  I mean they weren’t all that close together…” She glanced at Susan to see if she agreed.  Susan just blinked -a tired kind of boarding up of both her eyes. I think she could have fallen asleep if the room lights had been dimmer.

“And she says you’re still about four centimeters dilated.” Susan nodded, apparently wide awake again.

This seemed to deflate Mary, and she reached over and squeezed her husband’s hand. I could see a tear rolling slowly down one cheek. “Sometimes labour takes a while, doctor. I know I can do it,”  she said, and yet I could hear doubt mixed with fatigue in her voice. But her face was softer now. Gentler. She was not an unkind woman, but disappointment had robbed her of any dignity.

“I suspect you’re absolutely right about that, Mary.” I walked closer to the bed and stood beside her.  “But I think we’re going to have to do something to make those contractions more efficient.” Now that I was near, I could see the size of the baby distending her abdomen. It seemed huge.

Susan smiled at my expression. “I did an ultrasound last week and the estimated weight is over four kilograms.”

I took a slow, deep breath, but carefully preserved my smile for Mary. “It’s not the size of the dog in the fight; it’s the size of the fight in the dog…”

“I don’t…”

“It’s something my father used to say.”

One of Mary’s eyebrows elbowed its way past a brow furrow and for the first time she appeared amused… Well, anyway, not angry at me. “So you think maybe if you can make the contractions stronger..?” It was a question disguised as a clarification, hiding a deep sense of failure.

I tried to warm my expression. “Well, we can try…”

She studied me for a moment, knowing what I really meant. “But it’s an awfully big baby, you mean?”

I nodded slowly. Carefully. “But you know, sometimes the body is full of surprises,” I said, mindful of the pun.  “In medical school we were always taught that the the secret to a successful labour depends on the combination of Power, Passageway, and Passenger.” I hesitated for a moment. “But sometimes, no matter what we want, and no matter what we do, there is no choice…”

“What do you mean?” her husband said, genuinely puzzled. But fearful. His eyes darted between Susan and Mary like little birds looking for a branch.

Mary sighed and squeezed his hand again. “He never guesses the murderer on the Mystery Channel either, doctor.” Her expression softened as she looked up at him; he seemed so worried for her. “The doctor just means if we can make the contractions stronger, they may be able to push the baby out.” She glanced at me to see if she’d got it right. There was a wisp of a smile lurking just out of sight on her face. I think she was actually looking forward to the challenge.

I ordered an intravenous infusion of oxytocin to augment the contractions, but despite that, after another three or four hours of gradually increasing the dose, even with the stronger and more frequent contractions she hadn’t progressed at all.  Sometimes you just have to admit defeat -or at least claim your victory on a different field.

When I walked in to tell her she would require a Caesarian Section, she wasn’t as tearful as I had anticipated. She was tired -exhausted, in fact- but cheerful. “Sometimes the first labour is a dress rehearsal, isn’t it doctor? You work out all the bugs, so when you try it again, you get it right…”

I nodded reassuringly. I had expected tears.

“So I can try for a vaginal birth for my next one, eh?” It was not so much a question as an entreaty.  And when I nodded my approval -Susan had probably told her I was usually in favour of trials of labour after Caesarians- she smiled. “I think my poor uterus was floundering this time. Probably hadn’t even read the instructions…”

And confident of her future triumphs, she chuckled all the way to the OR and presented me with a healthy, screaming eight and a half pound baby through her abdomen. Her smile spread through the OR like a virus. Some things, some people, are just contagious.

*

I never really forgot the incident, and for years I used her positive attitude as an example to others who required an unexpected and unwanted Caesarian. Like that dog my father had been so fond of mentioning, Mary was one of those who seemed to destined to snatch victory from the jaws of defeat. But, as years and patients slipped past with increasing speed, I realized I would probably never see her again. She became another nameless legend. Another in a long line of inspirational examples to be trotted out when the occasion demanded.

And then, one day there she was: the unforgettable short woman with the engaging, toothy smile. A little plumper than I remembered, and with little strands of grey in the weft of her short, brown hair, but Mary, nonetheless. And she seemed happy to see me.

“I finally decided to move on from the dress rehearsal, doctor,” she said, her eyes bright and twinkling, and her words somehow able to emerge intact through a grin that split her face in half. “I’ve always wondered which dog wins that fight…”

I checked the referral letter on the chart. She was only a month from her due date. I blushed inwardly; that accounted for the plumpness, for sure… “So congratulations, Mary,” I said with enthusiasm. “I hope things work out better for you this time.”

“Things worked out just fine last time, too, doctor.”

“Yes they did. Sorry we had to do the Caesarian, but sometimes there is no choice.”

“Unlike this time, I guess.” Her expression changed subtly, and then the smile returned. “I mean I do have a choice, right?”

I put my pen down and sat back in my chair. Her expression had shifted again. “Of course you do, Mary. Your pregnancy has been normal so far; there seems no necessity for a repeat Caesarian…” I stopped when I felt her eyes focussed on my face.

“But I want a Caesarian Section again, doctor.”

I have to admit my mouth fell open, and I became conscious of the need to close it.

“I was so young and naïve in my last pregnancy. So influenced by my friends…” She sighed and tried unsuccessfully to recapture her smile. “I don’t want a repeat of last time. There’s no need; I have nothing to prove.”

I put on my best doctor voice. “It may not turn out like the last time, Mary. Second labours are different. The body learns…” I could see my words bouncing off her cheeks. “I often tell my patients there should be a different name for second labours, so it wouldn’t engender the same expectations as the first.” Her head was still pointing at me, but I could tell her eyes were not listening. “You know, like the Inuit with their twenty-something different expressions for snow…”

“Whatever. I want a repeat Caesarian, doctor. I don’t want to take a chance on the snow.”

I shrugged my well-intentioned-defeat-shrug and told her I’d try to arrange an OR date for around the time she was due. “But,” I cautioned, “You may go into labour before that date -I mean how do we know?” I smiled as I got her to sign the operative consent forms. “And then you have a choice again.”

One eyebrow explored her forehead for a time. “What do you mean?” she said suspiciously.

“I mean that if you do show up in labour, you have a choice to opt for an emergency Caesarian -no one would bat an eye over that. Or… if you were dilating quickly, you could decide to see if the labour progressed. Our threshold for intervention is really quite low for a trial of labour. You wouldn’t have to worry that we’d try to force stronger contractions, or anything…” I suddenly realized it was me that was bargaining this time. Begging.

Her whole body stiffened. “Perhaps you don’t understand, doctor; I’ve already made up my mind. I do not want to go through another labour! I have made my choice.”

It sounded sufficiently litigious that I quickly nodded my understanding. It seemed the only wise thing to do.

*

As things happen, I was on call a few days before the scheduled OR date for her Caesarian. And, of course, she arrived in the Delivery Suite in heavy labour. She’d arrived by ambulance she was so worried and we rushed her into the assessment room to examine her. Her cervix was already almost fully dilated, and her contractions were coming fast and furiously.  I smiled to reassure her and ran out to book her for an emergency Caesarian. A stat section means right away and as luck would have it, the OR had just finished a case and had not yet sent for the next patient. They assured me they’d be ready for us if we wheeled the stretcher to the OR ourselves.

Just as I was hanging up the phone, however, I heard the nurse yelling for me to come, so I sprinted to the assessment room only to find the nurse trying to manage the baby’s head as it emerged through the vaginal opening. I grabbed a pair of gloves and took over the delivery of a large, healthy, crying baby girl. A precipitous labour and delivery. Who could have guessed?

After delivering the placenta, I inspected Mary for the expected trauma, but… nothing! The skin was intact; there was almost no bruising. Nothing to suture. Nothing to do really, except congratulate her on her new little girl.

But instead of a “Thank you so much!” or an “Am I every happy you were on call tonight!” it was a scowl that greeted me. A pair of furious eyes that followed me around the room as I cleaned things up.

“You lied to me, doctor!” she said through tense lips that barely moved. “You said I could have a Caesarian Section -that I didn’t need to go through another labour!”

I was speechless for a moment, and the room fell silent. The two nurses in the little alcove with me turned and stared at her, then thought better of it and left the area. My mouth opened, but no sounds came through it. I felt paralysed.

Suddenly her eyes relaxed and her face dissolved into laughter. It was the Mary of legend returned from the wilderness. “Had you there for a minute, didn’t I? Sometimes there is no choice… Didn’t you once tell me that, doctor?”

 

 

 

 

 

 

Pregnancies can be Miracles

The older I get, the more I wonder at the different Magisteria in which we become entangled. I am using the word in a metaphorical sense to mean sacred domains: sacrosanct issues rarely subject to closer interrogation -things we know because it is how we were raised, how our society apportions its sanctions and which, confirmation biases in tow, we could, were we so inclined, verify for ourselves with our own investigations.

Miracle, I suppose is another such metaphor. Its etymology is from the Latin mirari: to wonder at. Drawn as I am to Shakespeare, I remember Hamlet’s words to Horatio very early in the play: There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy. It is Hamlet commenting on the ghost of his murdered father; and perhaps Hamlet commenting on the limitations of the human mind as well…

So when I assert that in the course of my long career in obstetrics and gynaecology I have seen the occasional miracle, I do not want it misconstrued as religious, New Age, or even anti-scientific. With all the retrospective obfuscation that memory affords, I mean it in the original sense: something I wonder at.

Very early in my career, when I was wet with knowledge but experientially dry, I was on call for a colleague at the hospital. Those were exciting times when the textbook in my mind came alive. When the scenarios envisioned in the explanations blossomed into three dimensional reality, complete with an angst no writer ever mentioned. These were real people -real situations, jammed with emotions and consequences. An inaccurately assessed situation, an inexpertly performed procedure, an inability to decide on an appropriate course of action in what might seem to someone else as the blink of an eye, could be catastrophic. They were bewildering times, actually.

I was asked to see a woman -a patient of my colleague- in heavy labour who seemed to be making no progress. The cervix was not opening despite strong and regular uterine contractions, and the baby’s heart was beginning to show some signs of distress. There is a pattern and a progression to labour, and when things begin to deviate, the caregiver’s antennae begin to lengthen. We look for clues in the disparity: the fetal heart rate patterns associated with contractions, the mother’s condition, the amount and type of pain relief she both needs and received, the contractions themselves… Sometimes what clues exist are hidden -like they had minds of their own and did not want to be found. It can take patience to unearth them. Analyse them. Act on them. And that discovery time is sometimes fraught with danger to the mother – but more especially, to the baby. Occasionally the need to act, the need to intervene, is difficult to define and so difficult to explain to the parents. And yet it needs to be done. In older clinicians, there is probably an intuitive grasp of the situation -and not only a feeling that things are not right, but the vocabulary to explain it. I was not an older, experienced, battle-weary clinician. I did not yet have the words to justify my unease to the parents.

But I had to decide, and given her lack of progress in labour so far, I made the only decision I could under the circumstances: a Caesarian Section. She was only in her early twenties, as I recall and it was her first pregnancy. She and her partner saw the look on my face and readily agreed to the surgery.

I had done many Caesarian sections in my training -it is one of the operations with which most new consultants feel at least mildly comfortable. The procedure, though complicated and one requiring skill and good assistance, is simple enough in principle. One must gain access to the uterine wall by cutting through the abdominal skin and then separating the abdominal muscles to create enough space to see the uterus. Then the uterine wall is cut, the internal cavity entered, and the baby removed. But then the work begins: things have to be repaired -put back in place. And to do that, the placenta -the organ that has been feeding the baby until now- has to be removed. Normally, it is attached to the inner surface of the uterus like glue and comes free either with a little traction, or more commonly nowadays, by the anaesthesiologist adding something to the intravenous to make the uterus squeeze it out.

Her baby, a little boy, cried as soon as his head cleared the incision and I breathed a sigh of relief at his obvious health. Better a well-timed Caesarian operation that delivers a crying newborn, than one performed too late that doesn’t! Now I just needed to extract the placenta and close the incisions. But the placenta wouldn’t come out! I tried every trick I had been taught, and so did the anaesthesiologist but to no avail. And she was continuing to bleed. Heavily! Because of the amount of blood being lost, I realized I had to act quickly. The placenta seemed firmly attached to the wall, seemed to enter the uterine muscle, in fact.

Sometimes the placenta attaches a little too strongly to that inner wall -penetrates it, even. And then the nightmare begins: the invasive quality of the placental attachment can take it right into, or even through the wall of the uterus so it can be seen on its outer surface.  And under those circumstances, there are very few options -especially if she’s bleeding uncontrollably. The medications to make the uterus contract do not work in the area of perforation of the placenta (called a placenta percreta in the instance I am describing ). It’s usually deeply attached over a large area of the lining, even though only a small portion of it may have managed to reach right through the uterine wall. So, if all attempts to stop her hemorrhage fail -as they usually do under these circumstances- the only thing that can stop her from bleeding to death on the operating table, is a hysterectomy.

A caesarian hysterectomy is far more difficult than a more routine hysterectomy done at some temporal distance from a pregnancy. The tissues are more edematous and vascular for one thing -everything bleeds. And the anatomy is obviously altered and deformed by the size and shape of the just-pregnant uterus: rather than fist-size, it is basketball-or-bigger-size. And it bleeds uncontrollably until all of the arteries supplying it (with the same amount of blood it needed to nourish the baby) are cut and tied off. Lumps and bumps that would be easily recognized as fibroids (benign local overgrowths of muscle tissue) in the non-pregnant state often loom as large swellings sometimes indistinguishable from the rest of the huge mass of bleeding tissue that is a uterus in such distress.

Things were difficult, but controllable. I managed to find the requisite blood vessels supplying the uterus and systematically addressed them one by one to cut and tie them off. But just as I was about to tie one of the major ones, I noticed an unusual lump that, in the mad scramble to stop her hemorrhage I must have ignored. Now it seemed important. I hesitated to clamp the blood vessel on that side of the uterus, and instead examined the lump more closely. It didn’t seem to be a fibroid, or anything else I could think of. And then I saw the Fallopian tube. A normal uterus has two -one exiting from either side. Each one is charged with connecting the ovary to the uterine cavity. Charged with allowing sperm to travel along it to find an egg in the ovary, fertilize the egg, and then facilitate its way back to the uterus to implant in the inner wall as a pregnancy. The lump had a Fallopian tube attached to it.

She had, I guessed, what is commonly called a double uterus, joined to its baby-carrying twin at the cervix -sharing it, in fact. It hadn’t grown as large as the other side because it didn’t have a baby to accommodate. Of course I had never seen one before, but it looked like what I would expect it to. Actually, I’m not really sure what I expected one to look like, but on the spur of the moment, I decided to save it. To work around it. To take its bleeding, placenta-carrying sister out without its shared cervix and hope that the bleeding would stop.

The bleeding did stop and I finished the operation and then spoke to her frantic husband who was waiting in the lounge. We had asked him to leave the operating room when the bleeding had started because we’d had convert the spinal anaesthetic -with which we’d started for his wife- to a general anaesthetic to deal with all of her problems. I explained the need to remove her uterus to save her life and how close we’d come to losing that battle. Almost as an afterthought I mentioned the little nubbin of tissue I’d saved. He smiled wanly, probably not really understanding anything I’d said except that although his wife would live, they would not be able to have any more children. I don’t think he really understood how close she’d come to dying -after all, she was young and healthy and had only come to the hospital because she’d been in labour. People didn’t die in labour in this country. Nobody had mentioned it in their prenatal classes…

I suppose the reason I have come to regard this as extraordinary, is that after subsequent investigations, that little lump did turn out to be a uterus, albeit only half of what had been intended. But it did have its own Fallopian tube and an ovary. And she recovered well from the surgery. There’s always a silver lining if you look hard enough.

I subsequently lost track of her over the years. I’d heard from her family doctor that her menstrual periods had eventually returned, but as time and circumstance dictate, I eventually forgot about the incident.

And then one day she appeared in my office for a consultation. I didn’t recognize her at first, but I did remember her broad, engaging smile. She was one of those rare individuals who can make you feel both welcome and happy just by looking at her face.

I was obviously delighted to see her again, but puzzled by her visit. She looked well -radiant, in fact. Her face was ruddy, and her gait… familiar. She had a contented aura -almost visible- that extended far beyond her expression. Her eyes twinkled, as she sat on the other side of the desk and stared at me. Her face almost cracked with the smile.

“I didn’t get a note from your family doctor,” I stammered, not quite sure if I could believe what I sensed. I was no longer a neophyte. No longer an inexperienced beginner in my specialty.

“I told her not to,” she managed to say through the smile, and reached for my hand across the too-wide desk and across the vast bridge of time that separated us from our last meeting. She blinked slowly and contentedly and her face -her being– seemed to glow. “But you know, don’t you?” she added contentedly, softly – electricity travelling along her hand into mine.

My smile was no match for hers, but it was as big as my face could handle. I nodded, my eyes now locked on hers. “You’re pregnant, aren’t you..?” And we laughed together, like two children who realized they had shared the same secret.

I delivered a vigorously crying little girl four months later by another Caesarian section -a bit premature to be sure, but apart from being miraculous in both our minds, otherwise rather routine…